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Guidelines offer women a change of heart
(This article was first printed in the July 2007 issue of the Harvard Heart Letter.)
We’ve said this before and will, no doubt, say it again: Heart disease isn’t a man’s disease. It never really was, even though it has carried that reputation for years. Today, about one in every three American women is living with heart disease, the same proportion as men, and more women than men die each year of heart disease and stroke. Many women — and many of their doctors — don’t know this.
The burden heart disease places on women’s lives, their families, health care costs, and the economy is staggering. It is even more tragic when you consider that it is largely a preventable disease.
For the last 10 years, the American Heart Association (AHA) has tried to keep doctors and their female patients abreast of the latest knowledge on preventing heart disease. The association’s latest effort, published in the March 20. 2007 issue of Circulation, stresses lifestyle changes over medications, emphasizes a woman’s lifetime risk of developing heart disease, revises risk categories, advises against using hormone therapy or vitamins to prevent heart disease, and clarifies who should and who shouldn’t take aspirin.
Who’s at risk?
Prior guidelines used four categories of risk: high, intermediate, lower, and optimal. The new ones have just three: high risk, at risk, and optimal. A woman is in the high-risk group if she has some form of cardiovascular disease, kidney disease, diabetes, or a 20% or higher chance of having a heart attack over the next 10 years based on the Framingham risk score.
The at-risk category is quite broad. It includes women who have one or more risk factors for heart disease, such as smoking, inactivity, obesity, high blood pressure, high cholesterol, or a parent who developed heart disease at a relatively early age. Also included are women who do poorly on a stress test or who have evidence of atherosclerosis.
The optimal category is for the select few: women with a 10% or lower chance of having a heart attack over the next 10 years who also have healthy lifestyles and no heart disease risk factors.
Aspirin for some
It wasn’t until the completion of the Women’s Health Study in 2005 that we understood how aspirin might benefit women. This trial showed that taking aspirin didn’t prevent a first heart attack any better than taking a placebo, although it did slightly reduce the risk of stroke. When the researchers looked at aspirin’s effects by age, though, they found that it generally benefited women over age 65. These results are reflected in the AHA’s guidelines. They recommend daily low-dose aspirin for all women in the high-risk group and for some women in other groups who are over age 65, particularly those with well-controlled blood pressure in whom the benefits of aspirin for prevention outweigh the risks of gastrointestinal bleeding or hemorrhagic stroke. Healthy women under age 65 shouldn’t take aspirin to prevent heart attacks.
Priorities for prevention
The American Heart Association’s prevention guidelines for women list strategies proven to work, those that probably work, and those that don’t work. Virtually all of these apply to men, too, and do double or even triple duty against diabetes, cancer, and other chronic conditions.
Proven strategies
- Avoiding tobacco
- Exercising for at least 30 minutes a day, more if trying to lose weight
- Adopting a healthy eating plan
- Maintaining a healthy weight (a body mass index between 18.5 and 24.9)
- Controlling blood pressure, with medication if needed
- Controlling cholesterol, with a statin if needed
- Exercise, dietary changes, and medications if needed to control blood sugar
- Daily low-dose aspirin for women at high risk of heart disease
Probably effective
- Screening for depression
- Raising protective HDL with medications such as niacin or a fibrate
- Low-dose aspirin in women over age 65 with well-controlled blood pressure when aspirin’s protective benefits outweigh the risks
Not useful or effective to prevent cardiovascular disease, or may cause more harm than benefit
- Estrogen or other hormones
- Antioxidant supplements like vitamin C, vitamin E, or beta carotene
- Folic acid supplements
- Low-dose aspirin for healthy women under age 65
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Hormones for none
Hormone therapy is another confusing issue. Although hormones were once prescribed by many physicians to prevent cardiovascular disease, the landmark Women’s Health Initiative showed that taking estrogen with or without progesterone can actually increase the chances of having a heart attack or stroke. Based on this and other evidence, the AHA gives hormone therapy a general thumbs-down for preventing heart disease.
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